Review

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Dengue: an update on treatment options

Candice YY Chan*,1,2 & Eng Eong Ooi

Dengue is the most important mosquito-borne viral pathogen globally, with approximately
100 million cases of acute dengue annually. Infection can result in severe, life-threatening
disease. Currently, there is no effective vaccine or licensed antiviral. Management is primarily
supportive with fluids. Direct antiviral therapies that reduce dengue severity could be useful
although these would need to inhibit all four viral serotypes effectively. This review focuses
on the interventions that currently considered the gold standard in case management as well
as exploratory therapies that have been studied in clinical trials. Although antiviral drug and
therapeutic antibodies for dengue remain a work in progress, these studies have produced
some promising results and may have the potential to be future drugs.

First draft submitted: 20 April 2015; Accepted: 25 August 2015; Online: 23 November 2015

Dengue virus (DENV) is the most prevalent mosquito-borne viral hemorrhagic fever. DENV is Keywords
entrenched in over 100 countries in the tropics [1] . Endemic virus transmission, coupled with frequent • antiviral drug • dengue
cyclical epidemics, puts almost half of the world’s population at risk of infection each year [2–4] . • flavivirus • therapeutic
Both DENV and its mosquito vectors, principally Aedes aegypti, are also encroaching into nonen- monoclonal antibodies
demic areas due to increasing international travel and rapid urbanization with poor public health
infrastructure. Recent trends in global warming could further exacerbate the spread of dengue
vectors both northward and southward [5,6] . Besides causing mortality, the cost of acute illness to
society is considerably resulting from loss of productivity to costs arising from medical care [7,8] .
DENV belongs to the Flaviviridae family. There are four antigenically distinct serotypes of this
virus (DENV-1, 2, 3 and 4) [9] . A fifth serotype has been suggested although data demonstrating
its antigenic distinctness from the other four DENVs remain to be reported in the literature [10] .
The virus is enveloped and possesses a single-stranded positive-sense RNA genome [11] . The genome
is translated as a single polyprotein, which is then cleaved by host and viral proteases into three
structural proteins that collectively package the RNA genome: capsid (C), premembrane (prM),
membrane (M) and envelope (E) and seven nonstructural proteins (NS1, NS2A, NS2B, NS3, NS4A,
NS4B and NS5). The NS proteins encode enzymatic functions necessary for RNA replication and
evasion of host immune responses.

Overview of dengue pathology

In susceptible human hosts, DENV is thought to infect Langerhans cells at the site of mosquito
inoculation, which then migrates through the lymphatics. There, the infection then spreads to other
cells of hematopoietic lineages, including monocytes and macrophages, before further systemic

1
Department of Infectious Diseases, Singapore General Hospital, Singapore
2
Program in Emerging Infectious Diseases, Duke-NUS Graduate Medical School, 8 College Road, 169857, Singapore
*Author for correspondence: dr.candice.chan@gmail.com part of

10.2217/fmb.15.105 © 2015 Future Medicine Ltd Future Microbiol. (Epub ahead of print) ISSN 1746-0913
Review  Chan & Ooi
dissemination [12–14] . Viremia becomes apparent
1–2 days prior to the onset of symptoms, peaks
during days 1–2 of fever and declines over next
3–5 days until resolution of fever [9,11,15] . DENV
infection stimulates both innate and acquired
immunity. Innate immune response, such as com-
plement and type I interferon (IFN), functions
as the first line of defense against DENV [16,17] .
Acquired immune response involves serotype-
specific CD4 + and CD8 + T cells, which can
result in lysis of DENV-infected cells and pro-
duction of cytokines such as IFN-γ, TNF-α
and lymphotoxin [9,18,19] . Antibody response to
DENV is primarily targeted at prM, E and NS1
viral proteins [20–22] . Antibodies may neutralize
DENV by blocking virus attachment to cells
or by blocking viral fusion with cellular mem-
branes  [23,24] . Conversely, if antibody titers are
below the threshold necessary for DENV neu-
tralization, they may opsonize DENV and facili-
tate viral entry into cells that express Fcγ recep-
tors more efficiently. The result is an increase in
virus replication and higher risk of severe den-
gue, a phenomenon termed antibody-dependent
enhancement (ADE) of infection [25–28] .
●●Clinical presentation
Approximately a quarter of dengue infections
are symptomatic. In those who develop symp-
tomatic infection, there is a wide spectrum of
presentation and often with unpredictable clini-
cal evolution and outcomes [15,29] .
The symptomatic phase of dengue is sum-
marized in the latest WHO guidelines and is
divided into three phases: the febrile phase,
critical phase and recovery phase [15] . After an
incubation period of 4–10 days, the febrile phase
begins abruptly and lasts for 2–7 days. It is char-
acterized by acute fever and constitutional symp-
toms which could be debilitating (including
chills, malaise, headache, arthralgia, myalgia,
retro-orbital pain, anorexia, nausea, vomiting,
lethargy and rash). Thrombocytopenia, leu-
kopenia and variable rise in hematocrit (which
indicates vascular leak) develop. Dehydration
is commonly due to pyrexia, anorexia and
vomiting [15,18] .
The critical phase coincides with fever defer-
vescence and viremia resolution, lasting approxi-
mately 24–48 h. There is associated capillary
leakage, plasma volume loss and, if untreated or
improperly managed, shock [7,15] . It is hypothe-
sized that clinical complications are virus-driven
immunological responses [30–37] .
10.2217/fmb.15.105 Future Microbiol. (Epub ahead of print)
If the patient survives the critical phase,
recovery phase begins after 48–72 h. Patient’s
symptoms improve, and hemodynamic status
stabilizes with reabsorption of extravasated
fluid, along with rapid improvement in white
cell and platelet counts. However, if excessive
fluid therapy has been administered, patient
may develop ascites and respiratory distress from
massive pleural effusion, pulmonary edema or
congestive heart failure [15,38] .
●●Rationale for dengue therapy
Currently, treatment for dengue is largely sup-
portive. There is no licensed therapeutic drug.
Several clinical trials of therapeutic interventions
against acute dengue have been conducted and
several more are in progress. These therapies
target the virus, host immune responses or host
factors required by DENV to complete replica-
tion cycle. Some clinical studies reported higher
viremia levels (>tenfold) in patients with severe
(dengue hemorrhagic fever [DHF]/dengue shock
syndrome [DSS]) compared with nonsevere
(dengue fever) during early infection [30,39–41] .
This observed trend has led to the hypothesis
that reducing viremia by antiviral therapy in
the early phase of dengue infection may reduce
severity of clinically apparent disease [30,42,43] .
This review focuses on the clinical interven-
tion that is widely and currently considered
the gold standard in case management as well
as those that have been tested in clinical trials
as treatment for dengue. However, while devel-
opment in dengue therapeutics is in progress,
a number of practical challenges are already
apparent. Patients may present to healthcare
settings too late in their illness to benefit from
antiviral therapy. Differentiating dengue from
other febrile diseases is clinically difficult and
diagnostic tests are usually lacking in resource-
limited settings. Identifying patients at risk of
severe disease and therefore most likely to ben-
efit from antiviral treatment remains challeng-
ing. Furthermore, as viremia declines rapidly
after illness onset, antiviral treatment must be
fast acting. Dengue therapeutics development
must therefore be coupled with improved diag-
nostic and prognostic tools in order to translate
research into clinical practice.
●●Supportive therapies during acute dengue
Fluid therapy
Sensible fluid resuscitation is of paramount
importance in the management of patients with
future science group
 Table 1. Summary of clinical trials that assessed fluid resuscitation for the treatment of dengue shock syndrome.
Study (year) Design Setting  Patients Participants Fluid Intervention Conclusion Ref.
(n) 
Dung et al. Double-blind, Vietnam  Pediatrics ICU patients 50  NaCl 0.9%; dextran 7; Study fluid was Colloids may be superior to [47]
(1999) randomized, aged 5–15 years with 3% gelatin; Ringer’s administered for the first crystalloids, with more rapid

future science group

controlled trial DSS lactate 72 h restoration of hematocrit and
cardiovascular stability
Ngo et al. Double-blind, Vietnam Pediatric ICU patients 222 Dextran 70; 3% gelatin; Study fluid was No clear advantage to [44]
(2001) randomized trial (aged 1–15 years) with Ringer’s lactate; NaCl administered for the first using any of the fluids in
DSS without severe 0.9% 1 h, followed by Ringer’s cardiovascular recovery time.
hemorrhage lactate (WHO guideline*) Colloids were more likely to
benefit patients severe shock
Wills et al. Double-blind, Vietnam Pediatric ICU patients 383 with Moderately severe Study fluid was Requirement for rescue colloid [46]
(2005) randomized trial (aged 2–15 years) with moderately DSS group received administered for the first was similar for the different
DSS severe DSS; crystalloid (Ringer’s 2 h, followed by Ringer’s regimens. Significantly, more
129 with lactate) vs colloid lactate*. Patients with recipients in the dextran group
severe DSS (6% dextran 70 or 6% persistent shock after had coagulopathy and fluid
hydroxylethyl starch). administration of study overload than starch. Colloids
Severe DSS group fluid were given rescue performed similarly in severe
received dextran 70 vs colloids DSS. Ringer’s lactate should
starch be used in children with
moderately severe DSS
Kalayanarooj Randomized, Thailand Pediatric DHF patients 104 Colloids – 10% Doses of study colloids Both colloids were equally [48]
(2008) single-blinded (aged 8.6 ± 3.9 years) hydroxyethyl starch vs were given in boluses effective with no difference in
trial who initially received 10% dextran 40 when indicated at complications with regard to
crystalloid, but failed to clinician’s discretion fluid overload, renal functions
improve or developed and blood coagulation
fluid overload
*By WHO guideline 1997.
#
Abstract only.
§
Clinical diagnosis according to the WHO 1999 guideline.
DHF: Dengue hemorrhagic fever; DSS: Dengue shock syndrome.

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Dengue virus: an update on treatment options 
Review

10.2217/fmb.15.105
Review  Chan & Ooi

severe dengue, and a clinical algorithm has been

Ref.

[54]

[55]

[52]
published in detail in the latest WHO guide-
lines [15] . The goal is to prevent the complications
transfusion?

of vascular leakage and hypovolemic shock.

Theoretically, colloids provide volume expan-
Favor

sion over and above the actual fluid volume

No
No

No
infused. Colloid molecules increase plasma
oncotic pressure and promote retention of fluid
platelet count in the first 12 h, but no
difference was observed at 24–48 h
FFP may contribute to an increased

in the intravascular compartment. The magni-

tude of this effect is determined by the average
or resolution of bleeding. 7%
developed severe side effect
No benefit in the prevention

molecular weight of the colloid molecule and cir-

culation retention time determines the duration
of the effect [44,45] . For crystalloids, the plasma-
volume-expanding capacity is related to sodium
concentration. NaCl 0.9% (154 mM) in theory
Conclusion 

No benefit

may perform better than Ringer’s lactate (131

mM). In addition, there are theoretical risks of
worsening tissue acidosis and lactate accumula-
tion when large volumes of Ringer’s lactate are
Table 2. Summary of clinical trials that assessed prophylactic blood product transfusions in dengue patients.

infused  [44,45] . However, Wills et al. compared

Prophylactic
Prophylactic

Prophylactic
Treatment

Ringer’s lactate with two colloids and observed

platelets

platelets

no significant advantage of colloid compared

FFP

with lactate infusion in treating children with

DSS [46] . In addition, the effects of colloid were
Participants

transient, despite early rebound of hematocrit in

children receiving colloids during initial resusci-
tation; there was no difference between the dif-
266
109
(n)

87

ferent fluid regimens in terms of outcome and

severity of fluid overload 48–72 h after study
platelet count <30,000/μl without

thrombocytopenia (<20 × 103/μl)

infusion.
bleeding or with mild bleeding
platelet count <40,000/mm3

Besides the study by Wills et al., three other

Adult dengue patients with
Dengue adult patients with

Adult patients with severe

without clinical bleeding

trials have been conducted to compare the differ-

ent types of fluid resuscitation regimen of DSS.
Table 1 summarizes all four such randomized
without bleeding

controlled trials [44,46–48] . Taken collectively,

there is no clear advantage to the use of col-
Patients 

loids in terms of the overall outcome. However,

colloids may be the preferred choice if blood
pressure needs to be restored urgently (in those
with pulse pressure <10 mmHg) as they have
Singapore
Sri Lanka 

Pakistan

been shown to restore the cardiac index and

Setting 

hematocrit faster than crystalloids in patients

with intractable shock [44,46–48] . Furthermore,
the overall low (0–0.2%) mortality of the study
Lye et al. (2009) Nonrandomized,
nonblinded trial

population supports the importance of carefully

controlled trial
double-blind-

retrospective
Sellahewa et al. Randomized,

Randomized,

cohort study

titrated fluid therapy to maintain vital functions

during the vascular leakage period without over-
Design

filling the intravascular space and meticulous

FFP: Fresh frozen plasma.

supportive care for patients with DSS.

Study (year)

Blood products to reduce bleeding

Assir et al.

complications
(2008)

(2013)

Thrombocytopenia (platelet count below 150

× 109/l) is a hallmark of DENV infection and

10.2217/fmb.15.105 Future Microbiol. (Epub ahead of print) future science group

 Dengue virus: an update on treatment options  Review

usually observed between days 3 and 8 following

Ref.

[57]

[58]

[59]

[60]

[61]

[62]

[63]
the onset of illness. Platelet count plummets in
parallel with a rising hematocrit, indicative of pro-

(Underpowered)
Favor steroids?
gression to the critical phase of the disease. Platelet
count reaches nadir during defervescence (days
3–6), which is then followed by gradual sponta-
neous recovery [15,18] . Minor bleeding (mucosal,

Yes
No

No

No

No

No
petechiae) without hemodynamic instability is

No difference in duration of shock

No difference in duration of shock

or need for fluid requirement. No
years. Case fatality 44% (22 of 50)
common and usually resolves spontaneously. In

in nonsteroid group, and 18.75%

IV dexamethasone for Ineffective in increasing platelet

Ineffective in increasing platelet

patients with severe thrombocytopenia (defined

or need for fluid replacement

Favors steroids in children >8

Steroids not associated with

as ≤20 × 109/l), strict bed rest and avoidance of

IV methylprednisolone No difference in mortality

(9 of 48) in steroid group
nonsteroidal anti-inflammatory drugs and intra-

difference in mortality
muscular injections alone are usually sufficient to

prolonged viremia
reduce the risk of severe bleeding [15] .
Prophylactic platelet transfusion in patients
Conclusion 
without bleeding when platelet falls below 10–20
× 109/l is widely practiced in sepsis [49] , but is

count

count
not supported by evidence in dengue manage-
ment. First, a clear inverse correlation between

IV dexamethasone for
IV hydrocortisone × 1

Oral prednisolone for

platelet count and bleeding risk is lacking [50–53] .
IV hydrocortisone for
Rather, the two risk factors of severe bleeding are
IV hydrocortisone

prolonged shock and normal–low hematocrit at

the diagnosis of shock [50] . A summary of plate-

× 1 dose
let and fresh frozen plasma transfusion trials
3 days

3 days

4 days
Participants Drug

(Table 2) shows that current data do not support dose

24 h
prophylactic platelet transfusion given the lack
of sustainable and significant benefits [52,54,55] .
Table 3. Summary of clinical trials that assessed steroids as a treatment of dengue.

Furthermore, the benefits of treatment are out-

weighed by significant risks including fluid 200

Dengue patients aged 255

(n)

98

overload, transfusion-associated lung injury,

Children <15 years with 63
26

Indonesia Children <10 years with 97

61
­blood-borne infections and allergic reactions.
aged 12–65 years with
Children with dengue

Children with dengue

When major bleeding occurs, it usually arises

platelets <50 × 109/l

Adults with dengue

from the gastrointestinal tract and/or vagina in
Dengue patients

5–20 years ≤72 h

aged >18 years

adult females. Patients at risk of major bleed-
dengue shock

dengue shock

ing include those who have: first, prolonged or

Patients 

refractory shock; second, renal or liver failure;

shock

shock

third, persistent metabolic acidosis; fourth,

taken nonsteroidal anti-inflammatory drugs
or anticoagulants (e.g., heparin, warfarin) and
Thailand 

Sri Lanka
Thailand

Thailand

Vietnam
Setting 

fifth, preexisting peptic ulcer disease [15] . In

India

the event of severe bleeding, timely transfusion

of packed red cells, platelets and fresh frozen
placebo-controlled,

placebo-controlled,

plasma may be lifesaving.

double-blinded

double-blinded

double-blinded

double-blind
Randomized,

Randomized,

Randomized,

Randomized,

Randomized,

Randomized,
Nonblinded,
randomized

●●Therapies targeting the host immune

nonblinded

nonblinded
controlled,

response
Design

Corticosteroids
Corticosteroids have inhibitory effects on a
broad range of immune responses mediated by
Shashidhara et al.
Pongpanich et al.

Tam et al. (2012)
Tassniyom et al.
Min et al. (1975)

T and B cells as well as native immune responses

Sumarmo et al.

Kularatne et al.
Study (year)

IV: Intravenous.

of phagocytes. High-dose corticosteroids are of

benefit in many conditions with immune aber-
(2009)
(1982)

(1993)
(1973)

(2013)

rancy, notably autoimmune diseases such as sys-

temic lupus erythematous [56] . In a double-blind

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Review  Chan & Ooi
placebo-controlled trial, the use of corticoster-
oids during the early acute phase of dengue
infection showed no effects on shock, plasma
leakage or platelet count recovery in dengue
patients. It also did not change the kinetics of
dengue virological markers or plasma cytokine
concentrations (Table 3) [57–63] . In summary, the
use of steroids cannot be recommended [64] .
Intravenous immunoglobulins
Intravenous immunoglobulins (IVIG) is an
accepted treatment for idiopathic thrombocyto-
penia purpura (ITP). Thrombocytopenia in ITP
is attributed to autoantibodies called platelet-
associated IgG (PAIgG). PAIgG-coated plate-
lets undergo accelerated clearance through Fcγ
receptors expressed on mononuclear phagocytic
cells. The mechanism of IVIG is probably via
competitive inhibition of Fcγ receptors or liga-
tion of inhibitory receptors [25,26,65] .
A randomized, controlled study of 36 den-
gue patients was conducted to evaluate treat-
ment with IVIG according to the dosage and
frequency used for treatment of ITP for total of
4 days [66] . The study failed to show efficacy of
IVIG in promoting platelet recovery.
●●Mast cell inhibitors
Recent studies by St John et al. identified the
role of mast cell (MC) activation in the patho-
genesis of dengue-vascular leakage and hemor-
rhage [67,68] . During DENV infection, activated
MC was shown in a mouse model to release
various proteases, particularly chymase and
tryptase, into the serum that results in loss of
vascular integrity. Consistent with the observa-
tion in mice, the authors also showed that serum
chymase levels correlated with dengue severity
in patients enrolled in a prospective study. The
team then showed that MC-stabilizing com-
pounds, including cromolyn, montelukast and
ketotifen, reduced vascular leakage in wild-
type mice model of DENV challenge despite
small (but nonsignificant) increase in mice
viremia  [67] . Together, these data highlight the
potential of MCs as therapeutic targets to limit
DENV pathology. A proof-of-concept clinical
trial to test the efficacy of ketotifen to reduce the
degree of vascular leakage is currently in progress
in Singapore [Tambyah PA, St John A; Pers. Comm.] .
Target profile for a dengue therapeutic
There is still an unmet need for an effective
antidengue drug that can shorten the duration
10.2217/fmb.15.105 Future Microbiol. (Epub ahead of print)
of illness and prevent the development of severe
complications. Ideal properties for a future den-
gue therapeutics are summarized in Table 4. The
life cycle of DENV, drug targets and candidate
drugs are summarized in Figure 1 and reviewed
in detail elsewhere [69] .
●●Drugs targeting host factors required by
DENV to complete its life cycle
Chloroquine
Chloroquine (CQ ) was the first drug that
underwent clinical trial with reduction of viral
load as its primary end point [70] . CQ is a cheap
and widely available lysosomotrophic 4-amino-
quinoline derivative that is well established for
the treatment of malaria and inflammatory
disorders such as rheumatoid arthritis and sys-
temic lupus erythematous. In vitro, CQ inhibits
flaviviruses, retroviruses and coronaviruses by
interfering with pH-dependent steps of viral rep-
lication. In DENV infection, CQ inhibits endo-
somal fusion and furin-dependent viral matura-
tion, both of which are dependent on low-pH
environment in the endosome and trans-Golgi
network, respectively [70,71] . CQ also has immu-
nomodulatory effects by suppressing release of
TNF-α and IL-6, both of which may be respon-
sible for the inflammatory ­complications of viral
infections [72] .
In a randomized, double-blind placebo-con-
trolled trial of 307 Vietnamese adult patients
hospitalized with laboratory-confirmed DENV
infection, CQ-treated patients had longer dura-
tion of viremia [70] . There was also no appar-
ent reduction in the development of DHF.
Furthermore, CQ treatment was associated with
a significant increase in the rate of vomiting. In
a more recent small, randomized, double-blind
study of 37 positive dengue patients, CQ treat-
ment was shown to reduce the severity of pain
symptoms but failed to reduce disease duration,
the degree or days of fever [73] .
Celgosivir
DENV assembly occurs in the endoplasmic
reticulum (ER), where heterodimers of prM
and E proteins localize to the luminal side of
ER to form an immature particle. N-linked gly-
cosylation of prM and E proteins is required for
viral assembly and release of mature, infectious
DENV particles [15,74] . DENV infection also
induces ER stress, which activates the unfolded
protein response machinery. The expression of
UPR genes in turn activates various signaling
future science group
 Dengue virus: an update on treatment options  Review

pathways that induce apoptosis [75] .
Celgosivir is an alkaloid castanospermine
derived from the Moreton Bay Chestnut
tree [75] . Following oral administration, it read-
ily crosses cell membranes and is converted to
Cast, which inhibits the catalytic activity of
ER-resident enzymes, alpha-glucosidase I and
II. Both enzymes catalyze the removal of termi-
nal glucose residue attached to N-linked glycans
of newly synthesized glycoproteins. Inhibition
therefore is thought to result in misfolding of E,
prM and NS1 proteins during virus replication.
Celgosivir could also reduce cellular apoptosis
due to virus-induced ER stress [75] . In vitro,
celgosivir inhibited all four serotypes at submi-
cromolar concentrations [76] . Celgosivir-treated
mice showed reduced viremia, robust immune
response and increased survival upon lethal
DENV challenge, even when treatment was
delayed by 48 h after infection [75] . Celgosivir
was tested in Phase I and II trials as a possi-
ble treatment for HIV and hepatitis C infec-
tion and was found to be safe [75,76] . However,
the drug was not further developed because it
failed to demonstrate superiority over existing
treatments.
A Phase Ib, randomized, double-blind, pla-
cebo-controlled, proof-of-concept, single-cen-
tered trial to evaluate the safety and efficacy of
celgosivir as an antidengue drug (CELADEN)
was conducted in Singapore [77] . It recruited 50
PCR-confirmed adult dengue patients within the
first 2 days from illness onset. Individuals were
randomized to receive celgosivir for 5 days or
matched placebo. Results showed that celgosivir
treatment did not significantly reduce viremia,
fever or pain scores in patients with dengue.
White blood cell and platelet counts as well as
changes in hematocrit levels over the course of
illness were not different between treated and
placebo groups. Thus, the two proof-of-concept
trials for inhibitors of host factors of DENV
failed to show useful therapeutic efficacy.
Others (HMG-CoA-reductase inhibitors)
Inhibition of cholesterol synthesis may result in
faulty viral particle assembly and protein glyco-
sylation. 3-Hydroxy-3-methylglutaryl coenzyme
A (HMG-CoA) reductase inhibitors, known as
statins, have cholesterol-lowering effects and
established roles in cardiovascular risk reduc-
tion  [78] . They also exhibit anti-inflammatory
and endothelial-stabilizing effects and possible
antiviral effect targeting DENV virion assem-
bly [79] . In an AG129 model of DENV-2 infec-
tion, lovastatin increased survival rate when
administered either before or after infection [78] .
However, it only reduced viral load if given
before DENV-2 infection [78] . A randomized
controlled trial to evaluate the effects of lovas-
tatin on adult dengue patients is in progress in
Vietnam [80] .
●●Drugs targeting dengue proteins
Various direct-acting antiviral agents (DAAs)
have been developed that target specific den-
gue proteins. Interested readers can refer to
these excellent reviews on the latest develop-
ments, chemical structures and mechanisms
of actions of individual novel DAAs and thera-
peutic antibodies, which will not be discussed
in detail here [81–83] . Instead, we have provided
broad overviews of the development of these
approaches to treating dengue.

Table 4. Ideal properties of a dengue therapeutic.

Drug parameters  Ideal properties 
Spectrum Effective against all four DENV serotypes
Clinical outcome Rapid resolution of symptoms, reduced severity
Safety Well tolerated, minimal toxicity and does not require lab monitoring
Bioavailability Fast acting, high volume of distribution
Pharmacokinetic Sufficient half-life to enable infrequent (e.g., once daily) dosing to promote
compliance
Route of administration Oral rather than parenteral
Interactions Minimal with common drugs
Target population Adults, children, infants, pregnant women, patients with co-morbidities
(renal, hepatic)
Others Long shelf-life, stable without refrigeration to facilitate rural distribution
Cost Affordable in dengue-endemic countries
DENV: Dengue virus.

future science group www.futuremedicine.com 10.2217/fmb.15.105

Review  Chan & Ooi

DENV-Ab
immune complex Viral attachment
factors and receptors Entry inhibitors
1. E protein BOG hydrophobe
DC-SIGN pocket binder
Heparan 2. E stem trimer interaction
FCgR sulfate 3. Capsid (C protein) inhibitor
Mannose 4. CBA
receptor 5. Domain III-derived sequence
and attachment inhibitor
6. Heparin mimetic
TIM
pH 6.0
Fusion and Inhibit pH-dependant steps
virus dissembly of viral replication
Chloroquine
Polyprotein translation, TAM
transit to ER for processing

Virus poly-protein processing

Nucleus HSP70
and assembly in ER
Transcription/replication
pH 7.2 pH 6.7 RNA inhibitors
replication NS5 RDRP inhibitor
(Balapiravir)
NS3 helicase inhibitor
pH 6.0 NS5 methyltransferase
inhibitor
Furin cleavage
Nucleoside analogue
of prM
TGN
Viral protein Protein glycosylation
Virion budding glycosylation inhibitor
and release Celgosivir (alpha
glucosidase inhibitor)

Future Microbiology © Future Science Group (2015)

Figure 1. Schematic view of dengue virus replication cycle. (A) Virion binds to receptors on plasma membrane and enters the cell
via receptor-mediated or Fc-receptor-mediated phagocytosis if DENV is opsonized to cross-reactive or subneutralizing levels of
antibodies. (B) Within the acidic endosomal compartment, the E protein undergoes conformational change to mediate fusion of the
viral membrane with the endosome membrane, releasing the positive-stranded genomic RNA into the cytoplasm. (C) Genomic RNA is
translated into polyprotein. (D) Polyprotein is cleaved into individual proteins on the endoplasmic reticulum (ER) membranes by viral
and cellular proteases. (E) RNA replication occurs on the ER membranes in association with the viral replication complex composed
of NS1, NS2A, NS2B, NS3, NS4A and NS5. Viral assembly produces immature viral particles. (F) Immature viral particles (shown as spiky
virus particles) are transported through the secretory pathway. Lower pH in the trans-Golgi network activates the host protease, furin
to produce mature DENV particles (shown as smooth virus particles). (G) Release of mature virus into the extracellular space. Boxes
represent target sites of antiviral drugs or compounds. The bold red numbers refer to the pH values of the respective compartments.

Entry/fusion inhibitors types of cellular receptors and/or attachment

Entry of DENV into the host cell is mediated
mainly by E protein, which contains three
domains (DI, DII, DIII) [84] . In the mature
DENV particle, E protein is organized into 90
homodimers with the fusion loop concealed
inside the dimer interface. The first step of virus
entry is the binding of viral E protein to several
factors (e.g., DC-SIGN, heparin sulfate, man-
nose receptor, CD14, GRP78, laminin recep-
tor and TAM proteins) [85] . Following binding,
virus becomes internalized via clathrin-mediated
endocytosis  [85] . Inside the cell, the acidic pH
environment induces conformational change
and rearrangements of the E protein to expose

10.2217/fmb.15.105 Future Microbiol. (Epub ahead of print) future science group


and insert the fusion loop into the endosomal
membrane, followed by membrane fusion pore
formation to allow viral RNA to enter the cyto-
plasm. Membrane fusion inhibitors bind to
various portions of the structural envelope and
C proteins have been developed and recently
reviewed  [85] . Their future use awaits further
optimization, animal and clinical studies [82] .
Replication & transcription inhibitors
RNA-dependent RNA polymerase inhibitor
(balapiravir)
NS5 is the largest and most conserved nonstruc-
tural protein in DENV as well as other flavivi-
ruses. NS5 contains two enzymatic domains: first,
the N-terminal methyltransferase (NS5-MTase)
domain and second, the C-terminal RNA-
dependent RNA polymerase (RdRP) domain
(NS5-pol). Balapiravir is a product of a nucleoside
analog (4’-azidocytine) called R1479, which was
initially developed for the treatment of chronic
HCV infection [86] . This drug inhibits viral NS5
protein, thereby reducing RdRP-dependent RNA
synthesis. It is not licensed for use in HCV due
to bone marrow suppression that arose with long-
term treatment given with pegylated IFN and rib-
avirin [87] . Dengue and hepatitis C share similar
RdRP architecture. A randomized, double-blind
placebo-controlled trial was thus conducted to
study the effect of a 5-day course of balapiravir
prescribed during the first 48 h of illness onset in
adult dengue patients [86] . Although the drug was
well tolerated, it failed to reduce either viremia,
NS1 antigenemia or fever clearance time. Plasma
cytokine profile and whole blood transcriptional
profile were not significantly different between
treatment groups. In conclusion, this trial did not
support balapiravir as a candidate drug.
MTase inhibitors
The NS5-MTase domain catalyzes RNA cap
methylation at both the N7 position of the gua-
nine cap and the 2’O position of the first nucle-
otide of the newly synthesized positive-strand
RNA  [88] . It can further methylate internal
adenosine of the viral RNA genome at the ribose
2’-OH position. N7 methylation of RNA cap is
essential for efficient translation, as mutations of
MTase that abolish N7 methylation are lethal
for flaviviral replication [88] . New compounds
(e.g., ‘compound 10’) are being developed that
selectively bind and inhibit MTase. At present,
suitable compounds are still being screened for
further testing [89] .
future science group
Dengue virus: an update on treatment options  Review
Nucleoside analog (NITD008)
An adenosine analog NITD008 was devel-
oped that exhibits antiviral effect via inhibi-
tion of DENV RdRP and termination of RNA
chain synthesis [90] . In vitro studies showed that
NITD008 reduced DENV 1–4 replication.
DENV-infected mice treated with NITD008
demonstrated reductions in viral load, proin-
flammatory cytokines and mortality. However,
this drug also showed significant side effects
during preclinical toxicology studies in mice,
and therefore not further developed for clinical
trials [90] .
Helicase inhibitors
Helicase inhibitors work by inhibiting DENV
NS3 unwinding activity during RNA replica-
tion  [91] . Recently, a novel small-molecule heli-
case inhibitor (ST-610) was identified. This
compound potently and selectively inhibited all
four serotypes of DENV in vitro  [92] . In mice,
it was well tolerated and effective in reducing
viremia. However, this drug has poor oral bio-
availability and requires parenteral administra-
tion, hence limiting its use especially in resource-
limited settings.
Protease inhibitors
The DENV NS3 is a serine protease in associa-
tion with NS2B as a cofactor. During DENV
replication, correct co- and post-translational
processing of the polypeptide gives rise to the
structural and nonstructural proteins and is
therefore essential for virus replication [93] .
These steps require multiple proteases derived
from the host (e.g., furin) and virus (NS2B/
NS3). Viral proteases are proven antiviral targets
as demonstrated by the highly effective HIV-1
and HCV protease inhibitors [93] . DENV 1–4
NS3 protease shares 63–74% sequence similar-
ity, suggesting that although it is plausible to
develop effective protease inhibitors against all
four DENV serotypes, the barrier to resistance
could be low. Several potential protease inhibi-
tors have been identified (including 166347,
ARDP006, thyrothricin, compound 23i and
compound 7n), but their development is still
in its infancy and to date no drugs have been
evaluated in vivo [82] .
NS4B inhibitor
NS4B is a transmembrane protein without
identified enzymatic activity but is required for
the formation and anchorage of the active viral
www.futuremedicine.com 10.2217/fmb.15.105
Review  Chan & Ooi
replication complex onto ER membranes [94] .
NS4B also interferes with IFN-α/β signal-
ing to promote virus propagation [95] . Several
groups have identified compounds that inhibit
DENV replication by targeting NS4B. NITD-
618 was one of the compounds that was identi-
fied and demonstrated to be active against all
four DENV serotypes [96] . However, NITD618
is highly lipophilic, which resulted in poor
pharmacokinetic properties that hindered its
testing in vivo  [82] . Lycorine, a plant alkaloid,
was another NS4B inhibitor with ability to
inhibit WNV, YFV and DENV 1–2 replica-
tion  [97,98] . Another compound, SDM25N,
was shown to be active against DENV 2 in
vitro [99] . The efficacy, safety and ultimate clin-
ical utility of NS4B inhibitors await f­u rther
clinical research.
Therapeutic antibodies
Therapeutic human serum polyclonal antibodies
(IgG), prepared from pools of plasma obtained
from multiple healthy blood donors, is assumed
to contain wide array of antibodies that would
be present in normal human serum and against
common viral pathogens [100] . However, the
disadvantage of polyclonal antibodies includes
batch-to-batch variations, risk of blood-borne
pathogens and multiple side effects especially
allergic reactions  [101] . Furthermore, batches
must be screened to ensure neutralization
activity against all four DENV serotypes [21] .
Therapeutic monoclonal antibodies (mAbs), in
contrast, can be produced in high quantities,
specificity and consistency with significantly
reduced adverse events associated with poly-
clonal IgGs [83] .
Antibodies targeting the lateral ridge or
A-strand of E protein EDIII can potently neu-
tralize some but rarely all four serotypes [102] . An
A-strand-specific mAb named 4E11 was rede-
signed through computational chemistry to neu-
tralize all four serotypes in vitro and in mouse
model of DENV challenge [103] . More recently,
the team further developed this humanized anti-
body by using a combination of computational
protein chemistry and X-ray crystallography to
further improve this antibody for therapeutic
application  [104] . This antibody is currently
undergoing preclinical development.
Alternatively, mAbs isolated from convales-
cent dengue patients that neutralize all DENVs
with remarkable potency may also have therapeu-
tic potential. Unlike mouse-derived antibodies,
10.2217/fmb.15.105 Future Microbiol. (Epub ahead of print)
human mAbs mostly bind quaternary epitopes.
de Alwis et al. identified a potent serotype-spe-
cific mAb that binds the hinge region between
EDI and EDII [105] . Teoh et al. identified a
potent serotype-specific mAb HM14c10 that
binds a discontinuous epitope spanning adjacent
surfaces of E-protein dimers on DENV-1 [106] .
Fibriansah et al. showed that a highly potent
mAb against DENV-3 binds the functionally
important domains across DI–III proteins [107] .
The same group also identified a DENV2-
specific human mAb 2D22 that binds across
E proteins and blocks the E-protein structural
reorganization required for virus fusion [108] .
Dejnirattisai et al. identified human mAbs that
bind epitopes that bridge across two E proteins
(called envelope dimer epitopes or EDE) [109] .
Interestingly, these antibodies show pan-sero-
type neutralizing activity and could be useful
therapeutically.
While therapeutic antibodies hold much
promise, they have only been studied in vitro
and in animal models. Molecular mechanisms
that operate and potentially influence the effi-
cacy outcome have been reviewed elsewhere [83] .
While these may have to be considered when
translating antibodies to therapeutic use, it
would nonetheless be interesting to see the pro-
gress of this form of therapeutics into the clinical
space as a treatment for an acute viral disease
like dengue.
Conclusion
Despite the large number of candidate com-
pounds that show antiviral effects against
DENV in vitro, few have been evaluated in clini-
cal trials. Although the optimal choice of fluids
in acute dengue is still debatable, meticulous
fluid therapy with close monitoring is the only
established standard of care that ameliorates
complications due to vascular leakage, shock
and organ failure. Drug discovery is hindered
by the lack of a reliable animal model of DENV
infection and the long expensive process of new
molecules discovery. It is hoped that efforts to
sustain and perhaps even accelerate the transla-
tion of bench-based findings into therapeutic tri-
als will continue in the coming years, especially
since a fully preventative dengue vaccine remains
challenging [112-114] .
Future perspective
While an effective therapeutic against dengue
remains elusive, the number of translational
future science group
 Dengue virus: an update on treatment options  Review

Executive summary
Spectrum of dengue infection
●● engue is an acute, systemic viral infection caused by one of four dengue serotypes in the family Flaviviridae,
D
transmitted by Aedes mosquitoes.
●● Dengue occurs primarily in the tropics.
●● engue presents with wide clinical spectrum, ranging from subclinical infection, or may cause mild dengue fever (DF),
D
to severe and even fatal dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS).
●● Death is usually primarily by plasma leakage, leading to shock, organ failure and hemorrhage.
●● Three phases of disease exist – febrile phase, critical phase and recovery phase.
●● There is no licensed drug or highly effective vaccine available at present.
●● linical assessment (history, physical examination and vital signs) and laboratory tests (complete blood count and
C
hematocrit) are required to assess disease phase and severity.
Dengue treatment: supportive therapy during acute infection
●● J udicious therapy is currently the cornerstone of managing acute dengue to prevent complications due to plasma
leakage, shock, organ failure and bleeding. However, excessive fluid can result in fluid overload.
●● T here is no clear advantage to the use of colloids over crystalloids in outcome. Colloids may be preferred in severe
(pulse pressure ≤10 mmHg) or refractory shock to quickly improve hemodynamic status.
●● Blood product transfusion is indicated in patients with major hemorrhage.
●● T hrombocytopenia is common in dengue during the febrile phase, but overt bleeding is uncommon. Prophylactic
platelet or fresh frozen plasma transfusion for severe thrombocytopenia in hemodynamically stable patients is not
beneficial and not recommended.
Dengue treatment: drugs targeting host immune response
●● T here is no evidence to support the use of intravenous immunoglobulins or corticosteroids in dengue and are not
recommended.
●● ast cells may be implicated in severe dengue via release of chymase and tryptase into the serum, causing vascular
M
leakage. So far, macrophage-stabilizing compounds have showed promising results in improving outcomes in mouse
models. Its therapeutic use in humans awaits clinical trials.
Drugs targeting host factors required by dengue virus to complete its life cycle
●● elgosivir, an alpha-glucosidase inhibitor, effectively inhibits dengue virus (DENV) 1–4 in vitro. In Phase Ib clinical trial,
C
it failed to demonstrate viral load reduction and clinical benefit.
●● hloroquine, a lysosomotriphic 4-amino-quinoline derivative, inhibits dengue through pH-dependent steps of viral
C
replication cycle and has ability to suppress cytokine-mediated inflammatory responses. No clinical benefit was
observed based on two randomized, double-blind studies of dengue patients.
●● holesterol-lowering drugs (statins) may exhibit anti-inflammatory and endothelial-stabilizing effects and possible
C
antiviral effect targeting DENV assembly. Lovastatin demonstrated survival benefits in mouse model of DENV infection.
Its use in humans awaits clinical trials.
Drugs targeting dengue proteins or direct-acting antiviral agents
●● rugs that target critical stages of dengue replication cycle (entry, fusion, translation, genome replication, protein synthesis
D
and egress) have been extensively studied. Most of these drugs have not been studied in animal models or humans.
●● alapiravir acts via inhibition of NS5/RdRP-dependent RNA synthesis. It is the only direct-acting antiviral agent (DAA)
B
that entered clinical trial. However, treatment with balapiravir failed to reduce NS1 antigenemia, viral load and fever
clearance time in dengue patients.
●● NS4B inhibitors act via inhibition of viral replication and prevents viral downregulation of interferon response.
●● T herapeutic mAbs that potently neutralize DENV by binding to the quaternary structures of envelope proteins without
antibody-dependent enhancement could potentially be used against homologous serotypes.
●● To date, no licensed dengue DAAs are currently available.

future science group www.futuremedicine.com 10.2217/fmb.15.105

Review  Chan & Ooi

studies that have been carried out is encourag-
ing. These efforts are long overdue against a
disease that results in significant global health
burden. As new studies are being developed,
downstream studies necessary for clinical
translation of any therapeutic should also be
actively considered. Since the great majority of
patients with dengue infection recover without
progression to DHF/DSS, studies to demon-
strate clinical benefits of therapy to prevent
severe disease would therefore require recruit-
ment of a very large number of patients. In
this context, perhaps there is an urgent need
to revisit human challenge studies that could
serve as proof-of-concept clinical trials to com-
plement therapeutic development. Such trials
can provide clear and definitive efficacy signals
and guide the design of larger trials. Such an
approach would prevent prolonged and expen-
sive clinical trials that often reach dead ends
due to insufficiently robust efficacy. Proposition
for human challenge studies has been discussed
elsewhere [110,111] .
Financial & competing interests disclosure
The authors have no relevant affiliations or financial
involvement with any organization or entity with a finan-
cial interest in or financial conflict with the subject matter
or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or
options, expert testimony, grants or patents received or
­pending, or royalties.
No writing assistance was utilized in the production of
this manuscript.

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